Notification of Involuntary Disenrollment by the Centers for Medicare & Medicaid Services for Failure to Pay the Part D Income Related Monthly Adjustment Amount (CMS-10352

Instructions for Completing the Notification of Involuntary Disenrollment by the
Centers for Medicare & Medicaid Services for Failure to Pay the Part D Income
Related Monthly Adjustment Amount—CMS-10352

Address and Salutation
1. Insert Part D plan sponsor letterhead: Insert the Part D plan sponsor’s letterhead that must
include the name and address of the Part D plan sponsor.
2. Date: Fill in the date that the notice is being mailed.
Body of the Letter—Paragraph 1
3. Member Name: Insert the name of the member whose Medicare prescription drug coverage
that has been terminated.
4. Disenrollment effective date: Insert the effective date of the member’s disenrollment that
was provided by the Centers for Medicare & Medicaid Services.
5. Part D plan sponsor name: Insert the name of the Part D plan sponsor that the member was
enrolled in prior to the involuntary disenrollment by the Centers for Medicare & Medicaid
Services.
6. Part D plan sponsor name: Insert the name of the Part D plan sponsor that the member was
enrolled in prior to the involuntary disenrollment by the Centers for Medicare & Medicaid
Services.
7. Disenrollment effective date: Insert the effective date of the member’s disenrollment that
was provided by the Centers for Medicare & Medicaid Services.
Body of the Letter—Paragraph 2
8. Part D plan sponsor name: Insert the name of the Part D plan sponsor that the member was
enrolled in prior to the involuntary disenrollment by the Centers for Medicare & Medicaid
Services.
9. Insert the date that is 3 calendar months after the disenrollment effective date: Insert the full
name of month, calendar day, and four digit year that is 3 full calendar months after the
effective date of disenrollment.

Body of the Letter—Paragraph 3/Bulleted List
10. Part D plan sponsor Name: Insert the name of the Part D plan sponsor that the member was
enrolled in prior to the involuntary disenrollment by the Centers for Medicare & Medicaid
Services.
11. Phone Number: Insert the telephone number of the Part D plan sponsor. This number should
be a customer service number or other number that the beneficiary can use to obtain
information about his/her Medicare prescription drug coverage including his/her premiums.
12. TTY: Insert the TTY number for individuals who are hearing impaired. This number must
be a customer service number (or other number) that the beneficiary can use to obtain
information about his/her Medicare prescription drug coverage, including his/her premiums.
13. Days and Hours of Operation: Insert the days and hours that the customer service or other
department is open. This must be the days and hours of operation for the customer service
(or other number) that can provide information to the beneficiary about his/her Medicare
prescription drug coverage, including his/her premiums.